Session content What is an initial assessment Starting strong Following the patients lead Initial assessment structure FAQ from past students therapists new to physical health What is an initial assessment ID: 476100
Download Presentation The PPT/PDF document "Initial Assessments – as a conversatio..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Initial Assessments – as a conversation not a quizSlide2
Session content:
What is an initial assessment
Starting strong
Following the patients lead
Initial assessment structure
FAQ from past students / therapists new to physical healthSlide3
What is an initial assessment
Objective can vary between assessments
Information gathering
OPI identification
Is OT indicated / what do they need from us?
It’s kind of like a maths equation:
medical event / illness + ??? = optimal level of function Slide4
Starting strong
Introducing your role and aim of session
Introducing self to all people present in the room
Tailoring your definition of OT to suit the context of the assessmentSlide5
Following the patient’s lead
Don’t expect the conversation to be necessarily linear!
Most people new to this style of assessment worry that they won’t gather all the appropriate information the first time or will forget to ask a question!
I have been working and doing these assessments for 8 years and I still forget to ask the odd question here and there – who cares! We can’t be perfect all the time!
Going where they lead and picking guiding questions to work from.Slide6
Initial Assessment
S
tructureSlide7
Consent / Notes / Role
How to document when the patient can’t give informed consent
Why read the notes
What you could document when you
don’t
see the patient at this pointSlide8
Client and Family Perspective
This is important as you need to give the patient and their family the opportunity to voice their perspectives and make their wishes known
Documenting this is very important also, and the way that you do this will influence how others see the person and their family
“we create the truth with our notes”
MY KEY RULES
:
NO JUDGEMENT
NO VALUE JUDGEMENTS
EMPATHISING WITH THE PATIENT DOES NOT MEAN THAT WE CONDONE THEIR ACTIONS / LIFE CHOICES, JUST THAT WE UNDERSTAND WHERE THEY ARE COMING FROM Slide9
Home Environment
Specifics are important – influences equipment prescription / home supports
This information will likely be forwarded on through subsequent admissions
Time saver in the next admissionsSlide10
Pre-admission Occupational Performance
Self-care / Leisure / Productivity
How to ask delicate / personal questions – changes depending on the age or background of the patient
Specifics like standing to shower in a cubicle is very different to standing to shower in a shower
over
the bathSlide11
Current
O
ccupational Performance
Abilities on the ward
Detail is important
State if you observed it / read it in notes (cite the date of the entry) / patient reported it to youSlide12
Occupational Performance Issues (OPI’s)
Can clarify in your mind what direction you are heading in with the patient during their admission
Clear identification of the issues is important as it allows the other members of the team to see Slide13
Goals
What does the patient want to get out of the admission?
Goals will be discussed further in a separate teaching sessionSlide14
Analysis / Plan
Analysis demonstrates your clinical reasoning
Rest of the assessment should be leading to that point / clear flow to that point
If you are going to discharge the patient you should have a clear reason why written in this section
My rule – no new information should appear in this section – it should be mentioned in the preceding sections
Plan with time frames and who you will be liaising with if appropriateSlide15
FAQ from students / therapists new to physical health
How do I get them back on track?
How do I record their complaints?
How do I ask about cognition without freaking out the patient?
How do I ask tactfully about toileting / continence without embarrassing them?
What if I forget to ask a question?
What if I can’t get all the information straight away – how do I record that?
They talked a lot but didn’t give me the information that I wanted – what do I write down?
They got so angry / upset at me / during the session for asking questions I had to leave – how do I document that?Slide16
Have I missed anything?
Please let me know if you have any other questions or if there are things that I could add to make the presentation better – flick me a message on the website and I will have a look!
Have a lovely day
Sonya